EN4.17 | Vertigo with Vestibular Function Assessment — Summary & Reflection

KEY TAKEAWAYS

Vertigo — the illusion of spinning movement — has a systematic approach based on episode duration and associated symptoms:

• BPPV: seconds, positional, no hearing loss; positive Dix-Hallpike (upbeat-torsional nystagmus, latency 2–5s, fatigable); treat with Epley manoeuvre (80% resolution, first-line).
• Meniere's disease: 20 min – hours, triad of vertigo + low-freq SNHL (fluctuating) + tinnitus + aural fullness; endolymphatic hydrops; manage with low-salt diet, betahistine, diuretics.
• Vestibular neuritis: continuous vertigo days – weeks, no hearing loss; unilateral canal paresis; treat with prochlorperazine acutely, then VRT for compensation.
• Peripheral vs central vertigo: peripheral = unidirectional nystagmus, positive HIT, suppressed by fixation, severe vertigo; central = direction-changing/vertical nystagmus, negative HIT, cerebellar signs — requires emergency MRI.
• HINTS battery: HIT + Nystagmus type + Skew deviation — use to distinguish peripheral from central in acute spontaneous vertigo; more sensitive than early CT for posterior fossa stroke.
• Caloric test: cold water = nystagmus opposite (away); warm = same; canal paresis >25% asymmetry = significant unilateral hypofunction.

REFLECT

The patient in the opening scenario has classic BPPV — brief, positional, no hearing loss, and a history of similar self-resolving episodes. She feared she was having a stroke, and her husband brought her in urgently. Reflect on how you would communicate to her that this is a benign, mechanical condition that can be cured in the consultation room with a simple manoeuvre — while not dismissing her fear. Consider also the patients in whom you might miss this diagnosis: an elderly person who says 'I feel dizzy when I get out of bed' and is empirically given antihypertensives — when the correct diagnosis is BPPV requiring only an Epley. What system-level change would most reduce missed BPPV diagnoses in a primary care setting?